Disorders of awareness of the body

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Bodily complaint without organic cause

Such conditions create difficulties for psychopathological understanding.

1. Aetiology is often obscure, sometimes with doubt that there may be an unrevealed physical cause.

2. The descriptive terms used come from different theoretical backgrounds and have changed their meaning over the years.

3. There is often discrepancy between the meanings attached to the symptoms by the patient and by the doctor.

ICD-10 lists a category 'Somatoform disorders' which includes both somatization and hypochondriacal disorders. (58) Somatoform disorders are characteristically repeated presentation of physical symptoms with persistent requests for medical investigation despite repeated negative findings and reassurance by doctors that the symptoms have no physical basis. The patient with somatization as the prominent disorder complains of multiple recurrent and often changing physical symptoms in different bodily systems over a prolonged time. However, the patient with hypochondriasis has a persistent preoccupation with bodily function, the possibility of illness, and the seriousness with which symptoms should be treated. Not infrequently these two groups of symptoms overlap. Comorbid anxiety and depression is quite frequent with both somatization and hypochondriasis. The content of hypochondriasis may take the form of delusion, overvalued ideas, hallucination, anxious or depressive rumination, or anxious preoccupation.

In ICD-10 the term 'Dissociative (conversion) disorder' has replaced the confusing but graphic term hysteria. Conversion symptoms can be categorized as motor, sensory (including pain), or psychological. Motor symptoms include weakness or paralysis of limbs or part of a limb and abnormality of gait; sensory symptoms include glove and stocking anaesthesia. Amongst the psychological symptoms is a narrowing of the field of consciousness with selective amnesia such as may occur in fugue states. For conversion disorder, or hysteria, to be diagnosed, symptoms should appear to be psychogenic in nature, causation should be thought to be unconscious, symptoms may carry some sort of advantage to the patient, and they occur by the mediation of the processes of conversion or dissociation.

Artefactual illness includes two categories: elaboration of physical symptoms for psychological reasons, and intentional production or feigning of symptoms or disabilities, either physical or psychological. Conversion symptoms are believed to arise without the patient's conscious involvement, but artefactual illness implies that the illness, lesion, or complaint is ultimately the individual's own conscious production. Malingering implies feigning or producing symptoms expressly for the social advantages of being regarded as ill, while the broader category of artefactual illness includes other motivations and simply describes the behaviour.

Narcissism is not generally accepted as a disease entity but is useful to consider as a psychopathological symptom. It is an exaggerated concern with one's self-image, especially with personal appearance. This absorption with self is usually associated with marked feelings of insecurity and ambivalence concerning the self, with feelings of threat to one's integrity.

Dislike of the body and distortion of body image are subjectively different experiences but often occur together, for example in anorexia nervosa or with gross obesity. In dysmorphophobia the primary symptom is the patient's belief that he or she is unattractive. Sufferers believe themselves to have a physical defect, such as the size of their nose or breasts, that is noticeable to other people, but objectively their appearance lies within normal limits. The dissatisfaction with their appearance, the extent to which they feel others are aware of disfigurement, the distress this causes, and the consequences in suicidal or other self-destructive behaviour are out of proportion to the significance of the abnormality, even if such an abnormality were present. The content disorder of dysmorphophobia takes the psychopathological form of an overvalued idea in which the degree of concern and consequent distress is clearly out of proportion and comes to dominate the whole of life. The overvalued idea of dysmorphophobia may be associated with an underlying personality disorder of anankastic or dependent type or with other psychiatric disorders.

Awareness of body size and disturbance of eating frequently occur together; alteration of body image is associated with eating disorder. Obesity in adolescence in diet-conscious Western societies frequently results in self-loathing, more frequently in girls than boys, with overestimation of body fatness and a pathological fear of seeing themselves in mirrors. Disturbance of body image occurs in sufferers from anorexia nervosa, characteristically an overestimate of width with an accurate estimation of height or the width of inanimate objects. The more 'over-fat' an individual considers herself to be, the more dissatisfaction with herself she will experience/59' Such disorders of self-image, with significant overestimation of size and discrepancy between perceived and desired size, also occur in bulimia nervosa and may be associated with depression of mood and feelings of guilt and unworthiness.

Organic changes in body image

Organic change may result from either damage to the conceptualized object (e.g. following amputation, with a phantom limb) or damage to the process of conceptualization (e.g. section of the corpus callosum). Hyperschemazia or pathological accentuation of body image occurs when physical illness or neurological lesion causes enhancement of perception of an organ. Diminished or absent body image (hyposchemazia, aschemazia) may occur when innervation is lost or with parietal lobe lesions. The diminution of body image may be simple (e.g. loss or neglect of a limb) or complex. There may also be distortions of the body image (paraschemazia) in which enhancement or diminution of parts of the body may occur.

Disorder of gender and sexuality

Core gender identity is established very early in life and then retained—biologically influenced and socially reinforced. Transsexualism is a disorder of gender identity, much more common in biological males, in which there is discrepancy between anatomical sex and the gender that the person assigns to himself. The subjective belief is an overvalued idea, often taken to an extreme degree. (See Chapt§L4.11.4 and Chapter9.2..1.2.)

The more commonly occurring disorders of sexuality can be divided, psychopathologically, into disorders of sexual preference, psychological and behavioural disorders associated with sexual development and orientation, and psychosexual dysfunction—conditions which are phenomenologically distinct. Subjective experience of deviance in sexual preference is largely determined by its social context; only those exhibiting behaviour that causes difficulties in relationships with others or is overtly illegal will usually be seen by a psychiatrist. Amongst disorders of development and orientation are those where the individual has uncertainty concerning gender identity and sexual orientation. Psychosexual dysfunction implies symptoms associated with normal heterosexual intercourse, usually divided into those occurring amongst males, those occurring amongst females, or problems in the sexual relationship.

Pain as a psychopathological entity

Pain is a subjective experience which only occurs in consciousness; it is hard to describe and categorize, and it is not well charted phenomenologically. It appears to have more in common with disorder of mood than disorder of perception. Pain associated with psychiatric illness tends to be more diffuse and less well localized and to spread with non-anatomical distribution. It also tends to be complained of constantly, becoming even more severe at times but persisting without remission. It may clearly be seen to be associated with underlying disturbance of mood which appears to be primary in time and causation. It is more difficult to describe clearly the quality of psychogenic pain. Psychogenic pain tends to progress in severity and extent over time. Persistent, severe, and distressing pain which cannot be explained fully by a physiological process or physical disorder has been designated persistent somatoform pain disorder. (See Chnapiteri5.2.6.)

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